Insurance Flood Endorsement Request

INSURANCE FLOOD ENDORSEMENT REQUEST

Insurer Name:   Policy Number:

Applicant / Insured Information

Telephone:   Email:

Date of Birth:

Property to Be Endorsed

Occupancy Type:   Year Built:

Policy Details

Policy Type: HO-3 DP-3 Commercial/Commercial Property Condominium Other:

Current Building Limit: $   Current Contents Limit: $

Current Deductible: $   Annual Premium: $

Policy Period Start:   End:

Requested Endorsement — Coverage Selection

Please indicate requested flood coverage additions and complete requested limits and deductible.

Building/Structure Coverage   Requested Limit: $

Personal Property / Contents Coverage   Requested Limit: $

Additional Living Expense (ALE)   Requested Limit: $

Debris Removal   Requested Limit: $

Other (describe below)

Requested Deductible: $   Requested Effective Date:

Exclusions and Limitations (Standard)

The requested flood endorsement, if issued, will be subject to policy terms, conditions, exclusions, and limits. Typical exclusions include but are not limited to:

• Loss or damage due to earth movement, landslide, subsidence unless caused by surface water overflow directly from a flood event; • Loss or damage caused by preparatory evacuation, voluntary relocation, or wear and tear; • Losses occurring prior to the effective date of the endorsement; • Losses caused by pollutants or contamination arising from flood waters not covered except to the extent specifically endorsed.

I acknowledge that I have read and understand the exclusions and limitations that will apply to any flood endorsement issued pursuant to this request.

Supporting Documentation Checklist

The following documentation is required to evaluate the endorsement request. Check those attached:

Elevation certificate or survey
Photographs of property / damage-prone areas
Documentation of mitigation measures (e.g., flood vents, raised utilities)
Prior loss history / claims records
Other:

Premium, Billing and Payment Authorization

Estimated Additional Premium: $

Payment Method: Check Credit Card ACH/Bank Draft

Beneficiary for Proceeds (Optional)

Beneficiary Name:

Relationship:   Allocation Percentage:

Certification and Authorization

By signing below, the applicant certifies that all information provided in this request is true, complete, and accurate to the best of the applicant's knowledge. The applicant authorizes the insurer and its representatives to obtain and verify any information necessary to evaluate this endorsement request, including inspection reports and loss history. The applicant acknowledges that issuance of any flood endorsement is subject to underwriting review, payment of any required additional premium, and execution of the insurer's standard endorsement form, which will amend the policy and become part of the policy contract.

The applicant further acknowledges that any misrepresentation or omission of material facts may result in rescission or denial of coverage and that coverage will not apply to loss or damage occurring prior to the effective date of the endorsement. Acceptance of an application does not guarantee placement; final coverage terms, conditions, limits, and exclusions will be set forth in the issued endorsement.

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